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9.

LUMPS IN THE GROIN AND SCROTUM


INTRODUcrlON

Swellings in these areas are common. They account for


about one in ten of outpatient presentations and are
therefore frequently found in finals examinations.
The majority of lumps in these areas are hernias. A
hernia is a protrusion of a viscus or part of a viscus
through an abnormal opening in the walls of its containing cavity. It usually has three components: the sac,
the coverings of the sac and the contents of the sac.

..

Hernias may be:


a. reducible
b. irreducible
c. obstructed
d. strangulated
An irreducible hernia is said to be obstructed if
intestinal obstruction complicates the hernia. The term
is not commonly used. If the blood supply to the hernia
is compromised (implying impending gangrene and
perforation) then the hernia is said to be strangulated.

.
./

/.

9. LUMPS IN THE GROIN AND SCROTUM


9.1 LUMP IN GROIN
Locale the lump anatomically
Anterior superior
iliac spine
INTERNAUDEEP
INGUINAL RING
Midinguinal point
with femoral artery
beneath it

EXTERNALJSUPERFICIAL
INGUINAL RING

Midpoint of the

"'"'"::::::.0.'"'" .]

Pubic tubercle
Pubic symphysis

'FEMORAL CANAL

SUPERFICIAL
Above and medial

INGUINAL RING
10 Ihe pubic lubercle

~------------

TransmitS cough impulse

I.
[FiEDUCIBL!'

I~GUINAL

HERNIA

FEMORAL CANAUTRIANGLE
Below and lateral to the pubic tubercle

No cough impulse

Testicle in scrotum

No testicle in scrotum

~.
Controlled by
pressure over

Not controlled by
pressure over

intemr ring

in,emr ring

INDIRECT

DIRECT

I-,--~I
Seep.46

Unilocular
Sofllump
Traction on the testis
causes the lump 10
move downwards and
become less mobile
Transitluminales

Testis maybe
coaxed into scrotum

RETRACTILE
TESTIS

Irreduere lump

I
ENCYSTED HYDROCELE
OFTHECORD

History of hernia

No treatment if
testis goes to
bottom of scrotum
If not relocate
via inguinal incision

IRREDUCIBLE
INGUINAL HERNIA

Excision if symptomatic

~
Pain
Tenderness
Bowel obstruction

Bowel obstruction

STRANGULATED

OBSTRUCTED

See p. 46

Testis cannot be
coaxed into scrotum

UNDESCENDED,
TESTIS
Relocation
in scrotum
Orchidopexy in
neonate belore
1 year old

9. LUMPS INTHEGROIN AND SCROTUM

~----

9.2 LUMP IN FEMORAL CANAlJTRlANGLE

------;/

Lymphadenopathy
Due to:
Local infection
Regional malignancy

or as part of a
generalized

lymphadenopathy

I LYMPH

I
NODE

Vascular lump:
Compressible
Blue
FillS slowly
Palpable thrill on coughing
Reduces when patient lies down
::!:. Varicose veins

I
SAPHENA

I.

VARIX

High saphenous

Rarer differe";lial

Spherical lump with


a narrow neck

FEMORAL

diagnoSiS

PsoasabscesQ

HERNIA

ligation
Reducible

(rarely)

REDUCIBLE
FEMORAL HERNIA

Irreducible lump

IRREDUCIBLE
FEMORAL HERNIA

~
Pain

rUctiOn

Bowelobst

Tendemess
BowelObf'ruction

C-rt'D

'I

OBSTj

STRANG1ULATED

See p. 46

.~
j

I
I

9. LUMPS IN THE GROIN AND SCROTUM


9.3 SCROTAL

LUMPS (1)

--------------------

Can 'get above if

Cannot 'get above it'

Confined to scrotum

Not confined

10 scrotum

May be reducible

Testis and swelling separately


Testis and swelling not separately

/r--

palpabte

~
I

HAEMATOCELE
Excision

bm

Controlled

Transilluminates

Theremaybea

secondary

hydrocele

present

due to the tumour

internarring

r----------_

Usually middle-aged palient

ULTR ASOUND

TUMOUR

HYDR OCELE

Orchidectomy through
inguinal incision
Staging, then deep X-ray therapy
and/or chemotherapy

Ex cision

by

pressure over

HYDROCELE
Testis is heavy and irregular

INGUINAL

Does not transilluminate

Hisloryol:
- trauma
- drainage of hydrocele

palpable

INDIRECT

HERNIA

Not controlled

pressure over
inlernatring

DIRECT

YOu~palient

Due t~ a palenlprocessus
Tunica albuginea and
processus vaginalis
distended up to but not
through the external inguinal ring

I
INFANTILE

f'YDROCELE

Ugation of patent processus

vaginalis

by

See p. 46

9. LUMPS IN THE GROIN AND SCROTUM.


9.4 SCROTAL

LUMPS (2)

Does nol transilluminate

Transilluminates

~
Tense lump
Situated behind testis
Size very variable
May be multiple

Unilocular
Soft lump
Traction on the testis
causes the lump
to move downwards
and become less mobile

Epididymis

affected

Firm, craggy
epididymis

I
EPIDIDYMAL

CYST.

Excision
(This may render
the patient infertile)

TREATMENT

ENCYSTED HYDROCELE
OFTHECORD

Especially

'Bag of worms'
marked when standing

if symptomatic

TUBERCULOUS
EPIDIDYMITIS

VARICOCELE
Excision if symptomatic

Excision

Post-vasectomy
May be tender

SPERM GRANULOMA
Excision

if symptomatic

Antituberculous
therapy

OF HERNIAS

Operation is the treatment of choice and may be performed using general, local, epidural orspinal analgesia.
All childhood hernias are indirect and a herniotomy
is performed. This'operation is the ligation of the sac. In
the adult with an indirect hernia the posterior wall of
the inguinal canal 'is repaired in addition - herniorrhaphy. If the hernia is direct and there is therefore no
indirect sac, herniorrhaphy alone is performed.

A reducible hernia in an adult should ideally be


repaired by herniorrhaphy. Any enlarging hernia, with
time, may become irreducible. This in itself is not an
indication for urgent surgery, but if symptoms of obstruction or ischaemia accompany it then immediate
surgical intervention is required.

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